Tricuspid Edge-to-Edge Repair Versus Tricuspid Valve Replacement for Severe Tricuspid Regurgitation

Background and Objectives@#Tricuspid valve (TV) repair techniques other than annuloplasty remain challenging and frequently end in tricuspid valve replacement (TVR) in complicated cases. However, the results of TVR are suboptimal compared with TV repair. This study aimed to evaluate the clinical effectiveness of TV edge-to-edge repair (E2E) compared to TVR for severe tricuspid regurgitation (TR). @*Methods@#We retrospectively reviewed 230 patients with severe TR who underwent E2E (n=139) or TVR (n=91) from 2001 to 2020. Clinical and echocardiographic results were analyzed using inverse probability of treatment weighting analysis and propensity score matching. @*Results@#The two groups showed no significant differences in early mortality and morbidities. During the mean follow-up of 106.2±68.8 months, late severe TR and TV reoperation rates were not significantly different between groups. E2E group, however, showed better outcomes in overall survival (p=0.023), freedom from significant tricuspid stenosis (TS) (trans-tricuspid pressure gradient ≥5 mmHg, p=0.021), and freedom from TVrelated events (p<0.001). Matched analysis showed consistent results. @*Conclusions@#E2E for severe TR presented more favorable clinical outcomes than TVR. Our study supports that E2E might be a valuable option in severe TR surgery, avoiding TVR.

Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis / 대한흉부외과학회지

BACKGROUND: Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians. METHODS: We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians. RESULTS: Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p<0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate. CONCLUSION: Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Outcomes of Coronary Artery Bypass Grafting after Extracorporeal Life Support in Patients with Cardiac Arrest or Cardiogenic Shock / 대한흉부외과학회지

BACKGROUND: Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. METHODS: We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1–Q3, 58–77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). RESULTS: The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1–Q3, 18.5–28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). CONCLUSION: CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.

Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis

BACKGROUND@#Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians.@*METHODS@#We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians.@*RESULTS@#Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p<0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate.@*CONCLUSION@#Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Outcomes of Coronary Artery Bypass Grafting after Extracorporeal Life Support in Patients with Cardiac Arrest or Cardiogenic Shock

BACKGROUND@#Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock.@*METHODS@#We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1–Q3, 58–77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%).@*RESULTS@#The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1–Q3, 18.5–28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%).@*CONCLUSION@#CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.

Life-Threatening Acute on Chronic Pulmonary Thromboembolism Requiring Extracorporeal Membrane Oxygenation

A 71-year-old female patient was admitted to the emergency department with sudden aggravation of chest pain and severe dyspnea. Computed tomography showed extensive pulmonary thromboembolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was instituted due to sudden bradycardia and hypotension. An emergency operation was performed. However, chronic pulmonary thromboembolism combined with an acute pulmonary embolism was detected in the operating room. Embolectomy and endarterectomy were performed. ECMO was then discontinued. The patient was discharged on postoperative day 13 with warfarin for anticoagulation. The patient was followed up for 46 months as an outpatient without further thromboembolic events.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects

BACKGROUND AND OBJECTIVES: Recently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance. SUBJECTS AND METHODS: We included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg. RESULTS: Fifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up. CONCLUSION: Thoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

Inter-Facility Transport on Extracorporeal Life Support: Clinical Outcomes and Comparative Analysis with In-house Patients

BACKGROUND: Extracorporeal life support (ECLS) is widely used in refractory heart or lung failure, and the demand for inter-facility transportation on ECLS is expanding. However, little is known about post-transportation outcomes, the clinical safety of such transportation, or the characteristics of the transported patients. METHODS: This was a retrospective review of a 3-year, single-institution experience with inter-facility ECLS transport, as well as a comparative analysis of clinical outcomes with those of in-house patients. We also analyzed the risk factors for hospital mortality in the entire ECLS population using univariate and multivariate analyses to investigate the effects of transport. RESULTS: All 44 patients were safely transported without adverse events. The average travel distance was 178.7 km, with an average travel time of 74.0 minutes. Early survival of the transported group seemed to be better than that of the in-house group, but the difference was not statistically significant (70.5% vs. 56.6%, p=0.096). The incidence of complications was similar between the 2 groups, except for critical limb ischemia, which was significantly more common in the transported group than in the in-house group (25.0% vs. 8.1%, p=0.017). After adjusting for confounders, being part of the transported group was not a predictor of early death (adjusted odds ratio, 0.689; p=0.397). CONCLUSION: Transportation of patients on ECLS is relatively safe, and the clinical outcomes of transported patients are comparable to those of in-house ECLS patients. Although matched studies are required, our study demonstrates that transporting patients on ECLS did not increase their risk of hospital mortality after adjustment for other factors.

Erratum: Inter-Facility Transport on Extracorporeal Life Support: Clinical Outcomes and Comparative Analysis with In-house Patients

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Persistent Atrial Fibrillation Related to a Congenital Pericardial Defect and Left Atrial Appendage Herniation

Congenital pericardial defects (CPDs) are infrequent anomalies that are usually asymptomatic and are discovered incidentally during unrelated interventions. Here we report the case of a CPD with herniation of an enlarged left atrial appendage identified during total thoracoscopic ablation (TTA) for persistent atrial fibrillation (AF). The persistent AF was successfully treated with a hybrid procedure, in which TTA was followed by an electrophysiological study.